Form 3596 Instructions CLASS/DBMD Plan 09-2014 PURPOSE The Plan is used to plan, document and justify the amount and frequency of authorized habilitation services. services consist of at least habilitation and may also include: habilitation training; Community Living Assistance and Support Services (CLASS) Direct Service Agency (DSA) representation on the service planning team (SPT); Deaf Blind with Multiple Disabilities (DBMD) habilitation service provider participation on the SPT; DBMD intervener services; DBMD day habilitation; medically-related delegated tasks; and/or CLASS prevocational services. CLASS and DBMD habilitation services support, but do not replace, non-waiver resources. PROCEDURE When to Prepare For CLASS: As part of the service planning process, the SPT determines the individual's needs to be documented on this form. When habilitation services will be delivered by the DSA, a DSA representative will document the SPT's deliberations on the form. When habilitation services will be delivered using the Consumer Directed Services (CDS) service delivery option, the case manager will document the SPT's deliberations on the form. This process occurs for development of an initial habilitation plan and is updated at the annual renewal and whenever habilitation tasks or other habilitation services are added or changed in the plan. The SPT reviews the Plan to determine the accuracy of the information included in the plan, including the frequency and duration of habilitation services. For DBMD:
As part of the service planning process, the SPT determines the individual s needs and may use the habilitation plan to document these needs at enrollment, when services are revised or upon renewal. This form may be used as a template for residential habilitation or intervener services identified by the SPT. This form may also be used for individuals directing their own services through the CDS option. Transmittal For CLASS: Completed and revised Plans are provided to the case manager. The Case Management Agency (CMA) files a completed Form 3596 in the individual's record. A copy is sent to the DSA, if necessary, individual/legally authorized representative (LAR), and the Financial Management Services Agency (FMSA), if applicable. An FMSA employer must maintain the completed Form 3596 in the FMSA record. The case manager retains a copy in the individual record. For DBMD: If the SPT utilizes the Plan to document the individual s habilitation needs, the DBMD provider should maintain a copy of the completed Form 3596 in the individual s record. A copy should be sent to the individual/lar, and the FMSA, if applicable. An FMSA employer should maintain the completed Form 3596 in the FMSA record. The case manager retains a copy in the individual record. Form Retention For CLASS, keep this form according to record retention requirements documented in the CLASS Provider Manual. For DBMD, keep this form according to the record retention requirements found in Texas Administrative Code, Chapter 49. DETAILED INSTRUCTIONS Individual Name Enter the name of the CLASS/DBMD individual. Date of Birth Enter the individual's date of birth. Medicaid No. Enter the individual's Medicaid number. Date Enter the date that the form is being completed. Money Management Assistance Needed Check "yes" or "no." If "yes," give the name of the person authorized by the individual/lar to assist.
IPC Period Enter the individual plan of care (IPC) period covered by the habilitation plan. Service Delivery Model Check Direct Service Agency (DSA), DBMD Provider, or Consumer Directed Services (CDS). Plan Check one of the following at the time the Plan is completed: Enrollment Renewal Revision No. Indicate the revision number. For example, the first time a revision is made during an IPC period is revision 1. This sequence starts over at the beginning of each IPC period. Note: Throughout this form, if the individual does not require assistance with a task, leave the field blank. I. Needs Sections 1 through 11 Time for Document in minutes the amount of time required to perform each activity. Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate.25, twice a month.5). Calculate the weekly total time spent on each activity by multiplying the Time for by the (Daily/). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.) For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence. Subtotal Add the weekly totals for each activity to determine the subtotal for each habilitation need. Section 12 Additional Tasks List additional habilitation tasks. Time for Document in minutes the amount of time required to perform each activity.
Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate.25, twice a month.5). Calculate the weekly total time spent on each activity by multiplying the Time for by the (Daily/). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.) For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence. Subtotal Add the weekly totals for each activity to determine the subtotal for each habilitation need. Section 13 Training Time for Document in minutes the amount of time required to perform each activity. Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate.25, twice a month.5). Calculate the weekly total time spent on each activity by multiplying the Time for by the (Daily/). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.) Subtotal Add the weekly totals for each activity to determine the subtotal for each habilitation need. Section 14 Medically-Related Tasks Time for Document in minutes the amount of time required to perform each activity. Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate.25, twice a month.5). Indicate Code Enter appropriate code (F, P, N, D, C) to indicate if the medically-related task is to be: F provided by family, friend or other non-waiver resource;
P physician delegated; N nurse; D RN delegated; or C Consumer Directed Services Calculate the weekly total time spent on each activity by multiplying the Time for by the (Daily/). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.) For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence. When habilitation training areas are identified on the Plan, Form 3597, CLASS Training Plan, must be submitted to establish specific training goals and plans for that individual participant to reach his/her personal goals for independence. Subtotal Add the weekly totals for each activity to determine the subtotal for each habilitation need. Section 15 Justification for Simultaneously-Delivered Services Explain the rationale for providing habilitation at the same time another service is provided (e.g., two habilitation providers are required to transfer the individual or the habilitation provider performs housekeeping tasks while the individual is receiving therapy or nursing services). Section 16 Additional Comments Document additional information related to the individual's habilitation needs and services. II. Schedule Indicate the time and days of the week the individual receives services for applicable activities and include weekly total hours by completing the following schedules. Section 1 Personal Care Services Complete the schedule for individuals who are under the age of 21 and receiving PCS services. Section 2 Nursing Indicate if services are provided through the CLASS or DBMD program or through other resources. If other, specify. Section 3 Therapeutic Services Indicate if services are provided through the CLASS or DBMD program or through other resources. If other, specify.
Section 4 Day Indicate if day activity is Day and Health Services (DAHS), CLASS Prevocational, Employment, Employment Assistance, Supported Employment, DBMD Day or Other. If other, specify. Section 5 Education Indicate if education is through School, Home- Schooled, Higher Education or Other (e.g., day care, or individual receives educational services from the school district in the home). If other, specify. Section 6 Intervener Complete the time and days of the week for the intervener, and weekly total intervener hours. III. Non-Waiver Caregiver Support Section 1 Living Arrangement Indicate if the individual lives alone, with parents, spouse/significant other, caregiver or other. If other, specify. Provide relationship, age and presence of a disability for all who reside in the same household as the individual. Sections 2-4 Caregiver Schedule Enter the name and relationship to the individual. Enter the start and completion time for hours spent each day at work and providing unpaid care to the individual. Work Schedules Document time the caregiver works. Unpaid Support/Supervision Provided to Individual Document time spent providing unpaid support/supervision to the individual. Additional Comments Provide additional comments relevant to caregiver schedules (e.g., if the individual's unpaid caregiver(s) also provides care and support to others in the home or has other barriers not indicated in this section, document that information. IV. Individual's CLASS/DBMD Schedule Special Instructions Document any unique circumstances related to meeting the activities of daily living or training needs of the individual in this section. Schedule(s) Enter the scheduled hours for the services to be provided to the individual (e.g., attendant, habilitation training, delegated tasks, prevocational, day habilitation or intervener). Use Schedule 2 if different schedules are necessary to meet the individual's needs (e.g., a school schedule for school-age individuals versus a summer and holiday schedule). If more than two schedules are necessary, use a separate page. Reflected on IPC (CLASS Only) Enter the number of covered weeks, weekly total hours and annual total hours for services to be provided by
habilitation staff (SVC 10 / CDS SVC 10V), habilitation training (SVC 10 / CDS SVC 10V), DSA representation (SVC 10), and medically-related tasks (SVC 10A). (Note: Service code 27A was changed to 10V.) Enter the number of covered weeks, weekly total hours and annual total cost for services to be provided for prevocational services (SVC 10B). Total Reflected on IPC (DBMD Only) Enter the number of covered weeks, weekly total hours and annual total hours for services to be provided by residential habilitation service providers (SVC 17/CDS SVC 17V), day habilitation (SVC 10), supported employment (SVC 37/CDS 37V), employment assistance (SVC 54/CDS 54V). Signatures/Dates The individual/lar, case manager, DSA/DBMD provider representative and all SPT members must review, sign and date the plan. File viewing information.
Form 3596 September 2014-E Community Living Assistance and Support Services(CLASS)/Deaf Blind with Multiple Disabilities (DBMD) Plan Individual Name Date of Birth Medicaid No. Date Money Management Assistance Needed? If yes, who provides this assistance? Yes No IPC Period Service Delivery Model Direct Service Agency (DSA) DBMD Provider Consumer Directed Services (CDS) Plan Enrollment Renewal Revision No. I. Needs 1. Hygiene Laying out supplies Daily Tub bathing and drying Daily Standby assistance for safety Daily Sponge bathing and drying Daily Bed bathing and drying Daily Assisting in/out of tub/shower Daily Shaving Daily Oral Hygiene Daily Caring for nails Daily Washing hands and face Daily Combing/brushing hair Daily Applying OTC lotion to skin Daily Washing hair Daily Drying hair Daily Applying makeup Daily Assisting with setting, rolling, braiding hair Daily 2. Toileting Hygiene Subtotal: Changing diapers Daily Assisting with female hygiene needs Daily Assisting with use of urinal Daily Changing external catheter Daily Assisting with clothing during toileting Daily Assisting on/off bedpan Daily Changing colostomy bag/empty catheter bag Daily Preparing toileting supplies and equipment Daily Standby assistance Daily Assisting with toileting hygiene; includes use of toilet paper and washing hands Daily Toileting Subtotal:
Individual Name Medicaid No. 3. Dressing Dressing individual Daily Laying out clothes Daily Undressing individual Daily 4. Shopping Picking up medication Daily Accompanying individual to pick up medications Daily Preparing shopping list Daily Putting away purchases Daily Accompanying individual to pick up items Daily 5. Meal Preparation Cooking full meals Daily Grinding/pureeing food Daily Cutting individual s food for eating Daily Serving food Daily Planning meals Daily Helping prepare meals Daily Warming up prepared food Daily 6. Feeding Spoon feeding Daily Bottle feeding Daily Standby assistance Daily Assistance with using eating/drinking utensils and adaptive devices Dressing Subtotal: Shopping Subtotal: Shopping Subtotal: Daily Feeding Subtotal: 7. Exercise Prescribed therapy exercises Daily Shopping Subtotal: Form 3596 Page 2 / 09-2014-E
Individual Name Medicaid No. Form 3596 Page 3 / 09-2014-E 8. Transfer and Ambulation Training Needed Positioning individual in bed/chair Daily Assisting with leg brace and prostheses Daily Transfers between stationary positions Daily Standby assistance with ambulation Daily Assistance with ambulation/using steps Daily Assisting individual to rise from a sitting to standing position and/ or position for use of walking/standing apparatus Daily Prescribed therapy exercises Daily 9. Cleaning For DBMD, individuals receiving chore services this section should include only light cleaning not encompassed by chore services. For CLASS, limit cleaning to three hours per week if individual lives with others. All cleaning activities must be limited to tasks directly related to meeting the needs of the individual. Training Needed Changing bed linens/making bed Daily Cleaning up after personal care tasks Daily Cleaning bathroom (i.e., tub/shower, floor, etc.) Daily Cleaning durable medical equipment Daily Cleaning floors of living areas used by individual Daily Cleaning bedroom Daily Dusting of living areas used by individual Daily Wiping stovetop, counter, washing dishes Daily Carrying out trash for pickup Daily Emptying and cleaning bedside commode Daily Gathering and sorting clothes Daily Loading/unloading machines in the residence Daily Hand washing of clothes Daily Hanging clothes to dry Daily Folding and putting away clothes Daily Using Laundromat services Daily 10. Community Assistance Shopping Subtotal: Cleaning Subtotal: Training Needed Arranging for transportation Daily Accompanying individual to doctor s office Daily Waiting in the doctor s office or clinic when necessary Daily Accompanying individual to planned outings Daily Community Assistance Subtotal:
Individual Name Medicaid No. Form 3596 Page 4 / 09-2014-E 11. Supervision Training Needed Health reasons Daily Safety reasons to prevent injury to self or others Daily Supervision Subtotal: 12. Additional Tasks A: Daily B: Daily C: Daily D: Daily E: Daily F: Daily Additional Tasks Subtotal: 13. Training For CLASS, Form 3597 must be submitted to access this service. Money management Daily Interpersonal communication Daily Self-care Daily Community integration Daily Reduction of maladaptive behaviors Daily Personal hygiene Daily Use of adaptive equipment Daily Accessing leisure time Daily Household tasks Daily Self-advocacy Daily Socialization/development of relationships Daily Mobility Daily Personal decision making Daily Accessing community resources Daily Restorative/compensatory strategies related to altered cognitive skills Daily Use of augmentative communication devices Daily Training Subtotal:
Individual Name Medicaid No. Form 3596 Page 5 / 09-2014-E 14. Medically-Related Tasks Indicate Code: F = Provided by family, friend or other non-waiver P = Physician Delegated N = Nurse D = RN Delegated C = Consumer Directed Services Time (Minutes) for Bowel program Daily Wound care Daily Suctioning Daily Administration of medications Daily Catheterization Daily Tube feeding Daily Trach care Daily Health Maintenance Activities Daily 15. Justification for Simultaneously-Delivered Services Indicate Code (F, P, N, D or C) Medically-Related Tasks Subtotal: Training Needed 16. Additional Comments II. Schedule 1. Personal Care Services Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Personal Care Services Hours:
Individual Name Medicaid No. Form 3596 Page 6 / 09-2014-E 2. Nursing Class DBMD Other Resources (specify): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Nursing Hours: 3. Therapeutic Services (Indicate the therapy type for each therapy listed in the therapeutic schedule.) Class DBMD Other Resources (specify): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Therapeutic Services Hours: 4. Day Day and Health Services (DAHS) Prevocational Employment Employment Assistance Supported Employment Day (DBMD only) Other (specify): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Day Hours: 5. Education School Home Schooled Higher Education Other (specify): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Education Hours:
Individual Name Medicaid No. Form 3596 Page 7 / 09-2014-E 6. Intervener (DBMD Only) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Total Intervener Hours: III. Non-Waiver Caregiver Support 1. Living Arrangement Who does the individual live with? Alone Parent(s) Spouse/significant Other Caregiver Other (specify): Provide relationship, age and presence of a disability for all who reside in the same household as the individual: Relationship Age Disability Relationship Age Disability Yes No Yes No Yes No Yes No Yes No Yes No 2. Caregiver Schedule Name: Relationship to Individual: Caregiver Support Monday Tuesday Wednesday Thursday Friday Saturday Sunday Work Schedule Unpaid Support Supervision Provided to Individual 3. Caregiver Schedule Name: Relationship to Individual: Caregiver Support Monday Tuesday Wednesday Thursday Friday Saturday Sunday Work Schedule Unpaid Support Supervision Provided to Individual 4. Caregiver Schedule Name: Relationship to Individual: Caregiver Support Monday Tuesday Wednesday Thursday Friday Saturday Sunday Work Schedule Unpaid Support Supervision Provided to Individual
Individual Name Medicaid No. Form 3596 Page 8 / 09-2014-E Additional Comments IV. Individual s CLASS/DBMD Schedule Special Instructions Schedule 1. Type of Service Monday Tuesday Wednesday Thursday Friday Saturday Sunday Schedule 2. Total Hours: Type of Service Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Hours: Reflected on IPC (CLASS only) Number of Covered Weeks Total Hours Annual Total Cost Services Schedule 1 Schedule 2 Schedule 1 Schedule 2 Schedule 1 Schedule 2 Attendant (SVC 10/CDS SVC 10V) Training (SVC 10/CDS SVC 10V) DSA Representation (SVC 10) Delegated Tasks (SVC 10A) Annual Total Hours:
Individual Name Medicaid No. Form 3596 Page 9 / 09-2014-E Number of Covered Weeks Total Hours Annual Total Cost Services Schedule 1 Schedule 2 Schedule 1 Schedule 2 Schedule 1 Schedule 2 Prevocational Services (SVC 10B) Supported Employment (SVC 37 CDS SVC 37V) Employment Assistance (SVC 54) Reflected on IPC (DBMD only) Annual Total Cost: $ Number of Covered Weeks Total Hours Annual Total Cost Services Schedule 1 Schedule 2 Schedule 1 Schedule 2 Schedule 1 Schedule 2 Residential habilitation (SVC 17/CDS SVC 17V) Day (SVC 10) Supported Employment (SVC 37/CDS SVC 37V) Employment Assistance (SVC 54/CDS SVC 54V Annual Total Hours: I agree to the above schedule and understand that I cannot exceed the number of approved hours within any given week as shown above. To accommodate unforeseen circumstances and to provide for flexibility in scheduling, I agree to notify the DSA/DBMD provider within an acceptable time frame, preferably five working days, of any changes I wish to make to this schedule. Signature Individual/LAR Date Signature Case Manager Date Signature DSA/DBMD Provider Representative Date Signature SPT Member Date Signature SPT Member Date Signature SPT Member Date